Pacemaker and irregularity?

pmabraham, BSN, RN · Jan 12, 2018

From my understanding, a pacemaker just paces the heart when certain lows or highs are hit; a combination pacemaker/ICD can be used if there's a chance for vfib. I've never seen a patient in Afib rvr given a pacemaker until their rates are controlled typically via medication management: amio, cardizen, ranolazine or otherwise converted to NSR. As you know, Warfarin doesn't deal with the rate or the rythm, and other options are eliquis, lovenox, etc.

offlabel · Jan 12, 2018

It's possible for a patient to have an irregular rhythm with a pacemaker, but unusual. One scenario I can think of is if there is afib with an A-V conduction blockade to one degree or another and there is a junctional brady that needs a pacer. That patient could have a ventricular pacer with an occasional atrial signal that conducts.

A pacemaker is not ordinarily therapy for the afib itself. If there is, I've never seen it. The problem with atrial pacing in afib is that the pacer would sense the atrial activity and inhibit itself, ie, not pace. You could, I suppose, demand pace the atria at a certain rate for bradycardia, but, again, that isn't for treatment of the afib itself.

Electrophysiologic ablation of afib is the definitive treatment for afib where the cardiologist "maps" the left atrium to determine where the foci of the fibrillation are and using radio frequency ablation, basically kill the cells that are causing the problem. It doesn't always give a permanent cure, but it is pretty effective.

Anti thrombosis therapy includes warfarin, but also Xa inhibitors and direct thrombin inhibitors.

brdavis17 · Jan 13, 2018

Ok, so if a fib is rate-controlled with amiodarone or other meds, will the heart beat still be irregular on occasion? Or should it be normal sinus? Would it be normal to hear occasional PVCs?

Also, if a patient has a pacemaker, is it normal for them to still have an occasionally irregular heartbeat, like PVCs or something? I ask because yesterday I was listening to a patient who had a pacemaker, also was on meds for a fib. I heard groups of 3 beats (and also heard those while I was taking her BP) and then that went away, and then I heard occasional dropped beats or an extra beat like maybe a PVC. I was wondering if this is cause for concern.

offlabel · Jan 14, 2018

Ok, so if a fib is rate-controlled with amiodarone or other meds, will the heart beat still be irregular on occasion? Or should it be normal sinus? Would it be normal to hear occasional PVCs?
Also, if a patient has a pacemaker, is it normal for them to still have an occasionally irregular heartbeat, like PVCs or something? I ask because yesterday I was listening to a patient who had a pacemaker, also was on meds for a fib. I heard groups of 3 beats (and also heard those while I was taking her BP) and then that went away, and then I heard occasional dropped beats or an extra beat like maybe a PVC. I was wondering if this is cause for concern.

Rate control meds don't permanently cure afib. They just decrease the amount of electricity that makes it to the ventricles from the atria. Extra "beats" aren't necessarily a concern with pacemakers. They're mostly not. Irregular rhythms aren't uncommon either.

PeekabooICU77 · Jan 18, 2018

I've definitely seen pacemakers implanted to treat a fib RVR indirectly. The idea is to beta-block the heck out of them for rate control and have the pacer set up at 60bpm (for example). I've seen many patients in a fib that are demand paced if the ventricular rate is lower than what the pacer is set to.

You can also see other atrial and ventricular ectopy with pacemakers. I usually see more ectopy if the pacer is set at a low rate. If the pacer is set to 80 or higher (just another example) we might be out-pacing the ectopy so it doesn't have a chance to be ectopic (lol).

Are you you in the inpatient setting? This sounds like a type of patient that would be on continuous monitoring. That would make it a lot easier than trying to guess if heartbeats were PVCs.

Pheebz777, BSN, RN · Jan 26, 2018

I have a few questions for cardiac nurses. Is it normal for a patient to still have an irregular rhythm with a pacemaker? Are pacemakers ever placed for a fib? Also, if a patient has a-fib, is the normal treatment warfarin to prevent a clot, but is there a long term solution to help control the heart rate?

It's not uncommon for PM patients to still have an irregular rhythm. The PM is only there to provide patient stability. The heart can still fire on it's own and trigger a ventricular response and the ventricles can also fire on it's own. You can see this especially with patients in severe sick sinus syndrome.

Some pacemakers have defibrillator capabilities (called AICD's) but for plain AFIB alone I haven't seen anyone who had a PM implanted for AFIB with a controlled ventricular rate.

ambersky004, BSN, RN · Feb 4, 2018

Ok, so if a fib is rate-controlled with amiodarone or other meds, will the heart beat still be irregular on occasion? Or should it be normal sinus? Would it be normal to hear occasional PVCs?
Also, if a patient has a pacemaker, is it normal for them to still have an occasionally irregular heartbeat, like PVCs or something? I ask because yesterday I was listening to a patient who had a pacemaker, also was on meds for a fib. I heard groups of 3 beats (and also heard those while I was taking her BP) and then that went away, and then I heard occasional dropped beats or an extra beat like maybe a PVC. I was wondering if this is cause for concern.

There are many causes of Afib and there different types of Afib. First priority is rate control because some people will always have an Afib rhythm. They call it chronic Afib. Some of these people are on Anticoagulant med.

Just like PVC's, they appear because of an underlying causes. If the patient has frequent PVC's after the pacemaker insertion, you need to find out what's causing it. If it occurs as trigeminy or triplets or more and the patient become symtomatic. You might need to look at their electrolytes level, if they are having any chest pain or shortness of breath or dizziness.

You have types of Pacemaker device. You will see a single lead pacemaker which carries impulse to right ventricle. You will have dual chamber pacemaker that carry impulses to right atrium and right ventricle.

2210485 · Feb 5, 2018

Different strokes for different folks. Some,management strategies opt for rate control ithers are more heavy on rhythm control.

For the rate control folks pacemakers are great for when you wanna ablate the AV Node (cause a 3rd degres Block) and just pace the ventricle.

For Rhythm control Pacemakers are great at fighting Heart Failure and keeping AFIB from returning.

Here are some things to remember about AFib (general info):

1. Most pacemakers have 'mode switching' features these days. That means when the afib starts only the ventricular component paces.

2. AFib as a disease is part of the same pathologic process that leads to AV blocks and Sick Sinus Syndrome. The majority of the AFib cases you see will likely have one of these other diagnosis. Thus many if these patients will already have pacemakers for some other indication when they start developing a noteworthy AFib burden.

3. Once a patient goes into AFib there pacemaker can't do anything about it. The only treatments from there are drugs, cardioversion or simply letting the patient break on their own.

4. AFib Ablation is the LAST line of defense. The procedure is transseptal and has a high rate of complication and failure. Afib ablation are also the most taxing procedures in terms of time and resources. They take anywhere from 4- 12 hours to complete and require almost twice the normal staff. 30% of procedures will have at least some form of complication. 30% of patients will ses the procedure fail and afib return in the next 10 years.

5. Once a patient is converted out of AFib an atrial pacemaker may assist in keeping the region responsible for the AFib suppressed for a longer period.

6. Frequent PAC's are associated with an impending episode of AFib and can give a rough estimate of how long a conversion will hold.

7. Best drugs to manage AFib are (in order of aggression, and often risk):

-Class 3 Anti-Arrhythmics:

Amiodorone (high success rate, but risk of toxicity)

Ibutilide (IV preparation only, very expensive, short supply but the only drug that's been studied and proven to be more effective than Amio. This drug also carries a lower risk of complication. It is the drug of choice in the EP lab.),

Sotalol (oral preparations available, common in most hospitals, less risky than Amio. Drug of choice to accompany a synchronized cardioversion)

- Class 1c Antiarrhythmics

Speaking from anecdotal experience class 1c seems to work better at controlling both AFib in addition to Ventricular ectopy. Propafenone seems to be a good selection for AFib, but Flecainide works as well. Flecainide would probably be best for PVC control of the two.

-Calcium Channel Blockers

Diltiazem and Verapamil.. Both very popular choices in Afib management. Diltiazem is the big winner here, common, affordable, patient can take it home.

- BetaBlockers

The tic tacs of antiarrhythmics. Appropriate for patients with low burdens or who need Beta Blockers to treat other issues such as hypertension anyways.

8. Thrombus and Stroke is a big risk for these patients. Most cardioversions, if not for immediately life threatening indications, will get a Trans-Esophageal echo prior to conversion. The TEE is vastly superior to the transthroacic ultrasound at visualizing the atrial appendages, which are the primary location where these thrombus like to hide. Exceptions to the TEE may exist in patients who only recently went into AFib on an inpatient unit, or those with aggressive anticoagulation stategies (e.g. INR over 1.8 for a long period). Local protocol will likely dictate the best course here.

9. Patients who do not wish to maintain their present anticoagulation strategy, have contraindications or in whom antithrombotic appraches fail may elect to have a 'Watchman' device implanted. Watchmans are basically just 'screens' or filters that sit in the appendage and prevent clots from embolising into circulation.

10. Afib and Aflutter are often confused. Having a regular rhythm doesnt really matter.. What if Aflutter has variable conduction? What if the variation is only 30 ms?

The easiest way to identify the difference is to look at lead V1. Measure the wave you see there, is it LESS than 200ms or .20 (5 small/1 big box)? If so, your patient is in AFib.

11. Proper pad pacement for a cardioversion for all ages is anterior-posterior (pediatric placement standard).

First, shave the areas I am about to describe. Clean the surface well with alchohol (not chlorohexidine or iodine) prior to pad application.

Place 1 pad on the anterior surface of the chest, just barely to the right of the sternum (sternal border). Place the other pad on the back just to the LEFT of the spine. It should not be sitting over the shoulder blade.. Avoid contact with thick bones as much as you can.

Look at your patient, do they look Small/Medium, Large or Huge? Set the defib to 100, 150 of 200 accordingly. Sync to the R Wave. Have someone place a pillow on top of the anterior pad and apply about 25 pounds of force (push hard). Shock. If unsuccessful, step up to 150 for small or medium folks, consider augmenting with Sotalol or Ibutilide for Large guys before stepping up to 200. Massive guys should get chemical augmentation jf they have not already. A second attempt at 200 can be tried. After that you will have to apply another set of pads and use a second monitor to deliver 2 shocks simultaneously. This all assumes biphasic shocks are the standard.

12. Scariest Afib ablation complication is pulmonary venous stenosis. Always watch your pt carefully when recovering a patient post Afib Ablation.

13. Afib is associated with CHF as well. Many Afib patients will need biventricular or 3 lead pacemakers to maintain ventricular synchrony.

14. Most Afib with RvR isn't an immediate life threat, however there is 1 exception:

Afib in patients with WPW or accessory pathways is an inmediate, life threatening emergency. If your patient had delta waves, and they develop AFib don't hesitate to call a Code Blue, a Rapid Response or the doctors personal phone or duty phone as the situation allows.

Without the AV Node to block excess impulses theres a chance that the afib will conduct directly to the ventricles. Afib conducting to ventricles without delay = Vfib =death. Its extremely serious and needs attention.

In terms of pacing, I saw something mentioned in this thread that reminded me of some more pearls:

If you suspect issues with pacing it's probably a good idea to just go ahead and draw up:

1. CMP

2. Blood Gas

3. Lactate

Drugs that improve thresholds for both pacing and defib/cardioversion would include Catecholamines (Epi/Norepi) and Corticosteroids (Cortisol/Solu-medrol). Never hearts to recommend these things to the doc if you guys are at a loss.